睿学教育Wisdome Education

Ivy Paige Altomare, MD

• Associate Professor of Medicine

https://medicine.duke.edu/faculty/ivy-paige-altomare-md

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A: X-ray of the right thumb demonstrates surgical amputation at the level of the interphalangeal joint anxiety 9 things trusted 60 mg cymbalta. B: Axial T1-weighted image of the thumb proximal to the amputation shows enlargement and redundancy of the digital nerves consistent with stump neuromas (arrows) anxiety symptoms change buy generic cymbalta. C: Axial T2-weighted image with fat suppression shows the hyperintense anxiety quitting smoking purchase cheapest cymbalta, retracted digital nerves (arrows). The fascicular appearance of the nerves is not well seen on this image due to motion. Fibroproliferative neuromas may occur after iatrogenic injury for lipomatosis of nerve. It is important for the clinician to recognize that each imaging modality has its advantages and disadvantages and one should not rely solely on the finding of a single imaging study if the clinical impression does not match. Randomized double-blind comparison of duration of anesthesia among three commonly used agents in digital nerve block. The free margin of margo liber of the nail is the portion of the nail which extends beyond the fingertip and can function as a very precise tool that can function in a tweezer-like manner as well as a knife and scrapper. It also serves to provide support to the pulp of the fingertip by providing counter-pressure against the fingertip. This support function enhances the tactile sensitivity of the fingertip by preventing distortion of the fingertip when touching or picking up an object. The nail matrix, or matrix unguis, lies at the base of the nail plate and contains arteries, veins, lymphatics, and nerves (Fig. The primary function of the nail matrix is to produce the keratin cells which form the nail plate. As the nail matrix produces new cells, the old nail plate cells are pushed forward which causes the nail to grow. The moon-shaped pearlescent lunula at the base of the nail plate is a part of the nail matrix. The base of the nail which lies underneath the skin just proximal to the lunula is known as the nail root (Fig. The eponychium, which is also known as the cuticle or proximal nail fold, is a thickened layer of tissue at the base of the nail plate at the proximal junction of the nail plate and the skin which functions to seal the area between the dorsal nail surface and the overlying epidermis. The nail matrix, or matrix unguis, lies at the base of the nail plate and contains arteries, veins, lymphatics, and nerves. The primary function if the nail matrix is to produce the keratin cells which form the nail plate. Lying beneath the nail plate is the nail bed which is made up of a superficial layer of epidermis which is attached to a deeper layer of dermis by a series of longitudinal grooves called matrix crests which becomes more visible as the nail ages. Lying at the junction of the free margin of the nail plate and the 581 underlying epidermis of the fingertip is the hyponychium, or quick, which serves to seal the nail bed (Fig. The onychodermal band is a translucent, gray area that is the point where the nail bed ends and serves to form a seal between the nail plate and the hyponychium. Lying at the junction of the free margin of the nail plate and the underlying epidermis of the fingertip is the hyponychium, or quick, which serves to seal the nail bed. Three common palmar digital arteries find their origin from the convexity of the superficial palmar arch and proceed distally on the second, third, and fourth lumbrical muscles to give off the proper palmar digital arteries which course along the sides of the index, middle, ring, and little fingers (Fig. The proper palmar digital arteries lie just below their corresponding digital nerves, each artery lying just dorsal to its respective digital nerve. The proper palmar digital arteries interconnect and anastamose with the smaller arteries which supply the interphalangeal joints and pulp of the fingertips (Fig. The proper palmar digital arteries also give off dorsal branches which anastomose with the larger dorsal digital arteries to provide blood supply to the dorsal second and third phalanges as well as the matrix of the respective fingernail (Fig. The ulnar side of the little finger is supplied directly from branches of the ulnar artery. Arising from modified smooth muscle cells is the glomus body, a specialized neuromyoarterial apparatus whose function is to regulate peripheral blood flow in the digits to aid in thermoregulation. A: Three common palmar digital arteries find their origin from the convexity of the superficial palmar arch and proceed distally on the second, third, and fourth lumbrical muscles to give off the proper palmar digital arteries which course along the sides of the index, middle, ring, and little fingers. B: the proper palmar digital arteries lie just below their corresponding digital nerves, each artery lying just dorsal to its respective digital nerve. The proper palmar digital arteries interconnect and anastamose with the smaller arteries which supply the interphalangeal joints and pulp of the fingertips.

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Excitation-contraction coupling anxiety xanax dosage cymbalta 20 mg otc, Molecular basis of muscle contraction anxiety symptoms jaw spasms buy cymbalta with visa, Cross bridge cycle anxiety zone best cymbalta 20 mg, Relationship between electrical and mechanical response in skeletal muscle, Types of muscle contraction, are usual Short Questions in exams. In Viva, examiners usually ask… What is the meaning of Excitation-contraction coupling, Who described Sliding-Filament Theory, What is the meaning of Sliding-Filament Theory, Steps in molecular basis of muscle contraction, Mechanism of calcium release from cisterns, Mechanism of cross-bridge cycle, Role of troponins and tropomyosin, Steps of muscle relaxation, Relationship between electrical and mechanical response in skeletal muscle and its importance, and Types of muscle contraction. Mechanism of skeletal muscle contraction is invariably asked in both theory and oral exams. Important properties of skeletal muscles (in addition to the If a second twitch is produced when the contraction properties, like contractility, excitability, fatigability, etc. Summation of contraction contraction of the second twitch is added to the phase of 2. Length-tension relationship is added to the Ca released due to the first action ++ 6. Load-velocity relationship potential, producing a higher sarcoplasmic Ca con- centration that results in a bigger contractile response. Summation of Contraction Therefore, the tension generated during summated response is greater than that of a single twitch. The It states that isometric tension developed in a single fiber tension increases further as the stimulus interval or a muscle depends on the frequency of the stimulus shortens (Fig. The action potential of the skeletal muscle is brief ation has occurred produces a phenomenon known as (1–4 ms) compared to its contraction time. Thus, during the contraction period, if the motor neu- If a skeletal muscle is stimulated rapidly (but below the ron is stimulated repeatedly, it will generate several tetanizing frequency) with a maximal stimulus, there is action potentials in the muscle fiber. The contractile a progressive increase in the force of contraction for the Chapter 28: Skeletal Muscle: Properties, Fiber Types and Applied Aspects 267 A B Figs. Note that the second stimulus applied before relaxation period of first response leads to summation of con- C traction and increases in magnitude of contraction. This is the staircase phenom- If the muscle is stimulated repeatedly at a very high enon or treppe (in German). Treppe is also seen in cardiac frequency, continuous activation of the contractile mech- muscle. In 1871, Bowditch first described Treppe in the anism occurs without any relaxation, resulting in a sus- frog’s heart. In complete/fused tetanus, there is no relaxation contraction occurs during the relaxation phase of the between the contraction phases. In clonus or incomplete or unfused tetanus, there are to be higher than the first one (Figs. While the frequency of the action potentials progres- elevated as all the calcium released due to the first sively increases to tetanizing frequency, the tension stimulus has not been pumped back into the sarco- generated in the muscle gradually rises and summated plasmic reticulum. This leftover calcium is added to the calcium released this, tension does not increase further with increase in during the second contraction and results in greater frequency of the action potentials. This is known as staircase phenomenon as the graph is When a muscle is stimulated with a frequency more in an ascending order, like a staircase. The tension generated during a complete tet- There is an autoregulation method by which anus is usually about four times that of a single twitch. Following a single action potential, enough Ca is relea- phenomenon, Treppe effect or staircase effect. But, the attachment of activated myosin heads to Henry Pickering Bowditch in 1871, in cardiac ++ these sites takes time. Therefore, all the cross-bridges are not engaged and the tension‑generating mechanism is not saturated. In a tetanic contraction, more and more Ca is released with each successive action potential, exhausting the pumping-back mechanism. Thus, the cytosolic calcium remains at a constantly high level so that all the myosin-binding sites on the thin filaments are available. Such contraction occurs in a dis- ease called tetanus caused by the clostridium tetani.

Diseases

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In developing nations anxiety symptoms mayo generic cymbalta 20 mg on line, the age of onset of puberty is 11–16 years in girls and 13–18 years in boys anxiety symptoms 247 20 mg cymbalta order with visa. The period of transition from the non-reproductive state to the state of reproductive functions that allows Initiating Stimulus procreation is defined as puberty anxiety lymph nodes 40 mg cymbalta buy otc. During this period, the the increased secretion of adrenal androgen, called hypothalamic-pituitary-gonadal axis is activated to bring adrenarche, occurs about 1 to 2 years before the onset the gametogenic functions of the gonads to their thres- of puberty. Normally, gonads of both genders remain quiescent late the production of gonadal hormones that cause until the onset of puberty. Chapter 66: Physiology of Puberty and Menopause 585 Stages of Puberty Stage 3 Breast enlarges with enlargement of areola. Stage 4 Breast further enlarges with areola and papillae projecting Stage 1 out of it. Pubic hair becomes adult type, but covers smaller This is the preadolescent stage. Menstrual cycle starts (menarche), but irregular at of external genitalia (penis, scrotum and testes). Scrotum and testes are further some role in the determination of the time of onset of enlarged. This theory is sup- ported by the fact that experimental pulsatile injection Full adult pattern of sexual features develops. The pubertal development in females also described in five stages (by Tanner method, modified). It has been observed that body weight increases to a criti- cal level before the onset of puberty, especially in females. Stage 1 It is also observed that the onset of puberty is delayed in This is the preadolescent stage. Leptin, the hormone secreted from adipose tissue cell adrenal androgen is increased (adrenarche). This is supported by the experimental evidence that Breast development starts (thelarche). Breast paillae is injection of leptin in female mice results in precocious elevated and the diameter of areola is increased. But, the exact role of leptin in the control of puberty is hairs appear along the labia majora. Puberty may be delayed in spite of presence of normal gonads, which is called eunuchoidism in males and Abnormalities of puberty can be broadly classified into primary amenorrhea in girls. In females, ovaries become unresponsive to the puberty and precocious pseudopuberty. The functions of gonads slowly decrease finally resulting in complete cessation of menstrual cycle. Early development of secondary sexual characteristics, may be associated with premature development of Mechanism and Features gonads is known as true precocious puberty. This occurs due Mechanism of Menopause to early pubertal pattern of secretion of gonadotropin the mechanism and purpose of menopause are not clear. The female gonads progressively become unresponsive True precocious puberty occurs due to following to gonadotropins with advancing age. Hypothalamic precocity: Usually occurs due to tumor Ovaries stop secreting progesterone and estrogen in or infection of hypothalamus that causes premature appreciable amount. The uterus and vagina become gametogenesis without increase in gonadotropin atrophic. In males, though there is some decline in reproductive capacity from 5th decade of life, climacteric does not the development of secondary sexual characteristics with- occur. Testicular functions and potency persist till 8th out gametogenesis is called as precocious pseudopuberty. Thus, in males, there is no andropause (male This occurs due to exposure of immature males to abnor- menopause). Features of Menopause Precocious pseudopuberty occurs due to following causes: Hot flushes (sensation of warmth spreading from trunk 1.

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This distinction is anal fistulas and cross the internal anal sphincter anxiety symptoms 0f 60 mg cymbalta visa, then pass important to make anxiety symptoms and signs best cymbalta 20 mg, as the treatment of these diseases is very upwards and around the majority of the external anal sphincter different anxiety side effects cymbalta 40 mg purchase with visa. Fistulas which develop in an atypical location or do not heal regardless of multiple attempts with medical and surgical treatment point to a diagnosis of Crohn’s fistula. The terms trans-, supra-, and extra- refer to the exter- perianal abscess, fistula-in-ano, and pilonidal sinus. The pathogenesis of Crohn’s fistulas followed with a stronger emphasis on optimal medical remains poorly understood but is thought to be different than management to control rectal disease and reduce the autoim- that of the cryptoglandular form. The tract is then created by should trigger a search for active disease in the colon or small the pressure from the anorectum. Even if intestinal disease is not present, it is possible to ally more complex with branching and multiple tracts, which distinguish Crohn’s from cryptoglandular fistulas by identify- do not follow the typical pattern of cryptoglandular fistulas ing granulomas in the curettings from the fistula tract or areas or Goodsall’s Rule. Perianal skin tags may also yield fistulas, Crohn’s fistulas usually do not respond to operative pathognomonic non-caseating granulomas. Documentation of rectal mucosa involvement is a useful, noninvasive method which helps to distinguish essential to planning treatment. Fistulography mentioned, it can be difficult to distinguish between this is an older imaging modality which involves the injection of and other etiologies of perianal disease. Hidradenitis is a contrast into the visible external opening, with subsequent common diagnosis which may be confused with Crohn’s radiography. This technique has fallen out of favor for use in fistulas and may also occur in association with severe peri- perianal disease as it has been shown to have a low accuracy anal Crohn’s disease. A retrospective study showed that it was accurate in include additional tracts or abscesses within the groin or only four of 25 patients in delineating fistulas compared to armpit, multiple tracts in the perianal skin without connec- operative findings. Fistulography may be helpful in the cir- tion to the anal canal, and severe disease at onset rather cumstance of extrasphincteric disease or when used with than a gradual worsening in severity over time. The internal and external anal sphincters are well characterized, and therefore the relationship of the fistula tract to these structures can be determined. Undiagnosed patients may present with constant anal pain, For patients suspected to have complex disease extending pain with defecation, a painless draining perianal skin open- into the pelvis, such as in suprasphincteric fistulas, 1 mL of ing, a painful persistent abscess in the perineum, or unex- glucagon may be administered intramuscularly to help plained fever. Fibrotic fistulous tracts will a thorough history with regard to any prior episodes in the appear hypo-intense on T1- and T2-weighted images and past as well as other symptoms of Crohn’s disease including enhance with administration of gadolinium (Fig. A perianal and rectal exam should be but only granulation tissue will enhance with gadolinium performed in the prone jackknife position, looking for fistula (Figs. Buchanan found that disease recur- tracts, fluctuance, erythema, strictures, or skin tags. Sixty-three- gadolium, enhancement is homogenous throughout the fibrotic track year-old male with right lateral fibrotic intersphincteric fistula track. Current techniques in imaging of fistula in ano: containing tracks show peripheral low signal intensity and linear central 3D endoanal ultrasound and magnetic resonance imaging. Schwartz prospectively demonstrated disease extending into the pelvis or ischiorectal fossa [9 ]. Seventy- of intravenous gadolinium, granulation tissue enhances (arrows in b), seven-year-old male with transsphincteric fistula track containing gran- while fluid within a track does not. However, after the administration 2008;29:454–471, with permission) (97 % and 96 % vs. A small randomized, double blinded, placebo- controlled pilot trial at the Mayo clinic showed that remission Medical Therapy and response occurred more frequently (but not significantly) in patients treated with ciprofloxacin [15]. The use of cipro- Once a diagnosis of Crohn’s fistula is made, it is important floxacin and metronidazole remains widespread for the treat- to have a treatment strategy planned. Crohn’s fistulas are ment of this disease, despite the lack of conclusive evidence often very complex, and the initial treatment modality should of their benefit. Medical therapy may include appropriate antibi- otics, immunosuppressive agents, or biologic agents. There Immunosuppressants is no role for corticosteroids in the treatment of perianal Crohn’s disease.

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Each immunoglobulin mol- ecule yields only one F(ab′)2 fragment which is bivalent Papain (Figure 7 anxiety at night order cymbalta online. This aids efforts to reveal the molecular structure an IgG molecule deprives it of its ability to fx complement of immunoglobulins anxiety 8 year old son cheap cymbalta 40 mg fast delivery. Pepsin digestion molecule on the opposite side of the central disulfde bond is useful in diminishing the immunogenicity of antitoxins anxiety symptoms rash buy cymbalta uk. The Fc fragment of papain digestion has no antigen-binding Pepsin digestion refers to a proteolytic enzyme used to capacity, although it does have complement-fxing functions cleave immunoglobulin molecules into F(ab′)2 fragments and attaches immunoglobulin molecules to Fc receptors on together with fragments of small peptides that represent a cell membrane. Each immunoglobulin red blood cell surfaces susceptible to agglutination by incom- molecule yields only one F(ab′)2 fragment, which is bivalent plete antibody. When an IgG molecule deprives it of its ability to fx complement the immunoglobulin is exposed to papain with cysteine pres- and bind to Fc receptors on cell surfaces. Pepsin digestion ent, papain cleaves a histidyl-threonine peptide bond of the is useful in diminishing the immunogenicity of antitoxins. Immunoglobulin fragment is a term reserved for prod- ucts that result from the action of proteolytic enzymes on pFc′ fragment is a fragment of pepsin digestion of IgG immunoglobulin molecules. Pepsin digestion of IgG or of the Fc can be severed by reduction in the presence of denatur- fragment yields low molecular weight peptides and a pFc′ ing agents such as urea, guanidine, or detergents. Similar cleavage of the heavy chain thymus-dependent and thymus-independent antigens, is more diffcult to achieve. Papain cleaves H chains at (2) augmentation of agglutination by lectins, (3) facilitation the N-terminus of the H–H disulfde bonds, giving two of the escape of cells from contact inhibition and culture, individual portions of the terminus of the molecule, called (4) enhancement of cytotoxicity with or without participation Fab, and the fragment of the C-terminus region, Fc, which of antibodies, and (5) stimulation of B cell proliferation. Thus, the two An antibody fragment is a product of enzymatic treatment Fab fragments will remain joined and are called F(ab′)2. For example, papain treatment which remain noncovalently bonded in dimeric form and leads to the production of two Fab and one Fc fragments, are called pFc′. Further digestion of the pFc′ with papain whereas the use of pepsin yields the F(ab′)2fragment. See the results in smaller dimeric fragments called Fc′Plasmin, individual fragments for further information. It may differ in size or shape ignated Fd, and the heavy chain portion of the Fab′ frag- from one antibody molecule to another. Antibody molecule specifcity is dependent of heavy and light chains on an immunoglobulin molecule on the complementary relationship between epitopes on anti- where antigen binding occurs. It is a 90-kDa enzyme that derives from cleavage of a sin- gle arginyl–valyl bond in the C-terminal region of plas- Binding site: In immunology, the paratope area of an anti- minogen. It consists of two unequal chains, termed heavy body molecule that binds antigen or that part of the T cell (A) and light (B) chains, linked by a single disulfde bond. It is comprised of one light chain and the seg- fbrinolytic activity, plasmin has numerous other functions ment of heavy chain on the N-terminal side of the central Immunoglobulin Synthesis, Properties, Structure, and Function 255 Fab Fd Fab s-s L chain s-s s-s Papain Fc Papain digestion digestion Fc´ figure 7. Fd fragment is the heavy chain portion of a Fab fragment produced by papain digestion of an IgG molecule. Division of the different amino acid num- ber at a given position by the frequency of the amino acid which occurs most commonly at that position gives the index of variability. It is also the extent of variability at each position and is useful in local- called Fc region, or Fc piece. This analytic method revealed that in immunoglobu- region linked by the central disulfde bond and noncovalent lin heavy or light chains most variable residues are clustered forces. This 50-kDa fragment is unable to bind antigen, but it in three hypervariable regions. Immunoglobulin Synthesis, Properties, Structure, and Function 257 is comprised of one light chain linked by disulfde bonds to Fab the N-terminal segment of heavy chain. This 95-kDa immunoglobulin fragment has a valence or antigen-binding capacity of two, which renders figure 7. However, the functions associated fragment consisting of the Fc region and one Fab region of the mol- with the intact IgG molecule’s Fc region, such as comple- ecule bearing a single antigen-binding site. Allelic genes that encode the γ1, γ2, and γ3 nal side of the central disulfde bond at the hinge region of heavy chain constant regions encode the Gm allotypes.

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D: Sagittal ultrasound image along the greater tuberosity of the humerus demonstrates needle aspiration of the fluid with the needle tip in the bursa anxiety 3000 order cymbalta 20 mg without a prescription. A high index of suspicion for infection of the subdeltoid bursa is indicated in any patient with shoulder pain and fever anxiety 3000 purchase cymbalta with a visa. Rarely anxiety and dizziness quality cymbalta 40 mg, tumors or other muscle abnormalities involving the deltoid muscle and subdeltoid bursa can occur. Magnetic resonance scanning may provide complementary information when used in conjunction with ultrasound evaluation of the subdeltoid bursa. Compromise of the subcoracoid space by tendinitis, boney deformity following fracture of the coracoid, or osteophytes can irritate the subcoracoid bursa and cause bursitis. It is also susceptible to irritation during extreme arm movement, when the biceps tendon is pressed against the humeral head (Fig. This process can be accelerated if previous trauma to the shoulder joint has compromised its stability and abnormal movement of the head of the humerus in the glenoid fossa occurs. Anatomic coronal section demonstrating the relationship of the coracoid process, the biceps tendon, 260 and the humeral head. The bursa serves to cushion and facilitate sliding of the musculotendinous unit of the subscapularis muscle. The bursa is subject to inflammation from a variety of causes with acute shoulder trauma and repetitive microtrauma being the most common. If the inflammation of the bursa is not treated and the condition becomes chronic, calcification of the bursa with further functional disability may occur. The patient suffering from subcoracoid bursitis most frequently presents with the complaint of severe pain especially with forward movement, internal rotation, and abduction of the shoulder. Activities requiring abduction of the affected upper extremity are particularly painful and the patient may complain bitterly of a knife-like catching sensation when using the shoulder upon first awakening. The pain of subcoracoid bursitis is localized to the area of the coracoid and is often referred to the medial shoulder. Physical examination of the patient suffering from subcoracoid bursitis will reveal point tenderness at the acromion process as well as in the subacromial region. If there is significant inflammation, rubor and color may be present and the entire area may feel boggy or edematous to palpation. Passive elevation and active internal rotation of the shoulder may exacerbate the pain of subcoracoid bursitis and the patient will often exhibit a positive adduction release test when the affected upper extremity is adducted against the examiner’s resistance and the resistance is suddenly and unexpectedly released (Fig. The coracoid impingement test may also be positive and is performed by flexing the shoulder 90 degrees, internally rotating the shoulder, and then horizontally adducting the arm. If calcification of the bursa and surrounding tendons has occurred, the examiner may appreciate crepitus with active range of motion of the affected shoulder. Rarely, the subcoracoid bursa may become infected and failure to diagnosis and treat the acute infection can lead to dire consequences (Fig. Septic subdeltoid and subacromial bursitis consistent with tuberculosis infection. A high-frequency ultrasound transducer is placed over the anterior glenohumeral joint in a transverse position and a survey scan is taken (Fig. The superior glenohumeral joint is identified and the ultrasound transducer is slowly moved medially until the coracoid process comes into view (Figs. If the subcoracoid bursa is highly inflamed, it may sometimes be identified as a hypoechoic fluid-containing structure with hyperechoic walls lying beneath the coracoid process (Figs. Evaluation of the overlying short head of the biceps tendon and the subscapularis muscle for pathology that may be responsible for the development of subcoracoid bursitis should also be carried out (Fig. Proper ultrasound transducer position for ultrasound evaluation of the subcoracoid bursa with the patient in the neutral position. Transverse ultrasound image demonstrating the relationship of the humeral head, the glenohumeral joint, and the coracoid process. Longitudinal (A) and transverse (B) views of the 7-mm thick heterogeneous mass (between asterisks in image A and arrows in image B) superficial to the subscapularis tendon consistent with subcoracoid bursitis. Subcoracoid bursitis as an unusual cause of painful anterior shoulder snapping in a weight lifter. Ultrasound image demonstrating subcoracoid bursitis associated with anterior subcoracoid impingement.

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Tertiary hyperparathyroidism is commonly seen in the setting of renal failure and renal transplant patients and results when the parathyroid glands become autonomously functioning anxiety symptoms without feeling anxious 40 mg cymbalta buy amex. Serum Parathyroid corrected Serum hormone calcium phosphate Primary ↑ ↑ ↑ hyperparathyroidism Secondary ↑ ↑ or normal ↑ hyperparathyroidism Tertiary ↑ ↑ ↑ hyperparathyroidism What imaging modalities can be helpful in localising parathyroid adenomas pre- operatively? Optic nerve Dural sheath Ophthalmic artery Sympathetics What runs through the superior orbital fissure? Medulla Meninges Vertebral arteries with its sympathetic plexus Spinal roots of accessory nerve Anterior spinal artery (formed from both vertebral arteries) Posterior spinal arteries Apical ligament of dens Tectorial membrane What runs through the foramen ovale? Mandibular division trigeminal (Vc) Lesser petrosal nerve Accessory meningeal artery Where is the internal auditory meatus located? Petrous temporal bone in the posterior cranial fossa What structures run through the internal auditory meatus? The extra-ocular muscles are innervated by the third (oculomotor) anxiety frequent urination generic cymbalta 60 mg mastercard, fourth (trochlear) and sixth (abducent) cranial nerves anxiety symptoms not going away purchase 40 mg cymbalta amex. The trochlear nerve and abducent nerve supply only one muscle, that is, the superior oblique muscle and the lateral rectus muscle, respectively. All the remaining muscles are supplied by the oculomotor nerve – that is, the superior rectus, inferior rectus, inferior oblique and medial rectus are all supplied by the oculomotor, or third, cranial nerve. Injury to any of these cranial nerves (third, fourth or sixth) may result in ophthalmoplegia and diplopia. The levator palpebrae superioris elevates the eyelid and has a dual innervation from both the oculomotor nerve and sympathetic fibres. The latter innervate a small smooth muscle portion of the levator muscle known as Muller’s muscle. The clinical significance of this dual innervation is that a third cranial nerve (oculomotor) palsy, or sympathetic interruption (Horner’s syndrome), may result in ptosis. To distinguish the two, it is essential to lift up the eyelid and inspect the pupil to see if it is enlarged (mydriasis in an oculomotor nerve palsy) or constricted (miosis in a Horner’s syndrome). In an oculomotor palsy, the eye points downwards and outwards from the unopposed action of superior oblique and lateral rectus, supplied by the fourth and sixth cranial nerves. Horner’s syndrome is associated with hemifacial anhidrosis, flushing symptoms and enophthalmos, in addition to ptosis and miosis. Posterior triangle of the neck What are the borders of the posterior triangle of the neck? Posterior border of sternocleidomastoid Anterior border of trapezius Middle one-third of clavicle Roof of skin, platysma, investing layer of deep cervical fascia and external jugular vein Floor of pre-vertebral fascia covering muscles, subclavian artery, trunks of brachial plexus and cervical plexus What are the contents of the posterior triangle? Nerves – Spinal root accessory and branches of cervical plexus Arteries – Superficial (transverse) cervical, suprascapular and occipital Veins – Transverse cervical, suprascapular and external jugular Muscle – Omohyoid with sling Lymph nodes – Level 5 What is the course of the spinal accessory nerve? It has been given the name spinal accessory since it originates from the upper end of the spinal cord (spinal roots, C1–C5). It passes through the foramen magnum and ‘hitches a ride’ with the cranial accessory nerve originating from the nucleus ambiguus. Its function is to supply only two muscles in the neck – the sternocleidomastoid and trapezius muscles. It traverses the posterior triangle of the neck from one-third of the way down the posterior border of the sternocleidomastoid muscle to one-third of the way up the anterior border of trapezius where it terminates (the ‘rule of thirds’). It is vulnerable to iatrogenic injury in procedures that necessitate dissection within the posterior triangle of the neck, such as excision biopsy of a lymph node. In a radical en-bloc lymph node dissection of the neck for malignant disease, the spinal accessory nerve may have to be deliberately sacrificed in order to obtain satisfactory clearance. What are the consequences of injury to the spinal accessory nerve in the posterior triangle of the neck? Damage to the spinal accessory nerve in the posterior triangle of the neck leads to a predictive weakness of the trapezius muscle. This results in an inability to shrug the shoulder on the side in which the spinal accessory nerve is affected and may result in winging of the scapula.

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Optic vesicle stage: This Is a transverse section through the optic vesicles at the third stage all nuclei and m itochondria anxiety cymbalta 40 mg. Lens placode stage: Showing collapse of the optic transparency and amazingly are not required by the cell anxiety buzzfeed trusted 20 mg cymbalta. Optic cup stage: is sustained via an extensive set of intercellular gap junc­ Embryonic tissues are labeled with the adult structures that they will later generate anxiety and chest pain purchase cymbalta mastercard. Interference with the delicate biochemical equilib­ almost entirely of precursor cells. A thinner layer tissue on the other side rium of the lens fiber cell might lead to cataracts, a of the optic cup will generate the pigment epithelium. The lens vesicle common disease in which lens crystallins aggregate in a has pinched off from the surface to become a hollow ball of epithelium, disorderly fashion, scattering light and rendering the lens and the portion facing the retina has begun to differentiate into lens fiber cells. The In the early optic cup stage, the lens vesicle releases sig­ transverse section has been made just postenor to the choroid fissure. This neural crest gives that Pax6 is expressed in several different ocular tissues rise to an internal cell layer known as the corneal endothe­ during their development. The epithelium, endothelium, and fibroblast crest ing from the head ectoderm, Pax6 expression appears to cells secrete additional collagen, forming the secondary define the boundaries of the early lens primordium32and is stroma of the embryonic cornea, which is sandwiched expressed in all nucleated cells of the mature lens, cornea, between these layers. As the thyroid gland tions in Pax6 have been associated with defects in the cor­ matures, increased thyroxin in the circulation stimulates neal epithelium54 and in Peters anom aly. The shape of the cornea makes specialized cells that also secrete glycoprotein a major contribution to refractive properties of the components of the vitreous. Growth of the vitreous is eye, and its malformation may lead to disorders such as apparently crucial to maintain the early growth of the astigmatism. Development of the retina and portion of the lens placode develops as the conjunctiva, its cell types proceeds in a highly regulated manner. It contains a large number of secre­ which appear near the vitreal face of the tory goblet cells that help maintain a lubricating mucous pseudostratified epithelium and send axonal fibers layer. During development, the eyelids furrow of the optic nerve tract, through the optic form as ridges on the dorsal and ventral edges of the chiasm and into the brain. The inner face of the eyelid, the palpebral conjunctiva, differentiation, most retinal cells remain is continuous with the bulbar conjunctiva that covers the undifferentiated precursors. In disorders Photoreceptors come in four types: rods, which are involving cryptophthalm os, in which the skin of the sensitive to low light and represent most receptors in forehead passes in an unbroken manner over the eyes the human retina, and the red, green, and blue cone and into the cheek, it appears that the lids either fail to cells, which require higher levels of light but respond form or degenerate, and that the ocular surface is trans­ more rapidly and can discriminate colors. This condition can exist on its own or in human and primate eye, the fovea is an area at the conjunction with other malformations, such as in b’raser posterior pole specialized for high-acuity color syndrom e. The internal neuroepithelium of the optic cup gives rise to the the origin of retinal cell types is apparently not deter­ retina, while the closely apposed outer cell sheet forms mined by an invariant cell lineage (Pig. One consequence of this basic organization sors could give rise to a variable assortment of neural and is that dividing precursor cells of the neural retina will glial cell types. Experiments with cultured retinal pre­ consequence is that ciliated cells develop along the cursor cells suggest that the primary, default pathway for ventricular face. Retinal photoreceptors contain a retinal development is the photoreceptor, and that signal­ ciliated process known as the outer segm ent that ing molecules from other cells arc required to induce the protrudes out into this space and is in close contact formation of other neurons and glia. The edges of the optic cup crucial for the functional maintenance of develop specialized structures under the inductive photoreceptors, it is interesting that the association is influence of the lens. The most marginal of these, the not a strong one, and injury can readily tear apart the iris, arises from the neural retina and pigment two layers, leading to a detached retina. These form a arises from the inner, neural retina layer, while the large gel mass, the vitreous. The vitreal, retinal, and choroidal precursors vasculature and the sclera that surround the retina are derived from a complicated mix of cells originating in Optic cup Committed the head mesoderm and the migratory neural crest cone precursor mesenchyme. In general, vascular endothelial cclls arc always derived from mesoderm, but the surrounding sm ooth muscle and connective tissue originates from the neural crest. Outside the sclera are the extraocular muscles, which attach to the sclera and control movement of the globe. In the early optic cup stage Ganglion embryo, neural crest and mesodermal cells migrate into cells Amacrine the choroid fissure and establish the hyaloid artery, cell which occupies the center of the optic nerve and early Muller Bipolar vitreous, and provides a vascular bed to sustain the lens glia cell during its development. In the congenital defect known as persistent hyperplastic Figure 1 J O rig in o f re tin a l c e ll types. Retina: precursor cells are long, spindle-shaoed primarily by budding from primitive retinal veins neuroepithelial cells that sDan the cell layer, remaining attached to both associated with the hyaloid artery, and invade the inner and outer faces of the retina.

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Although this ‘hypothesis’ makes intuitive sense anxiety 4th herefords buy cheap cymbalta 60 mg line, the surgery and became asymptomatic postsurgically [15] anxiety symptoms wiki purchase genuine cymbalta line. In the study by Kanner patients were unchanged in their psychiatric status: eight who et al anxiety symptoms shaking buy cymbalta 40 mg free shipping. Presurgically, 75 patients tients were women with primary right hemisphere seizure foci and (22%) met criteria for a diagnosis of depression, 59 (18%) of anxi- onset of their epileptic seizures afer adolescence. In this study, pre- ety disorders and 12 (4%) of other psychiatric disorders, including operative psychiatric diagnoses were not related to increased risk of bipolar illness and schizophrenia. In this study, the cluding pseudostatus epilepticus) increased postoperatively despite presence of an anxiety or depressive disorder postsurgically was not a signifcant improvement of their epileptic seizures. She was found to have a lesion in the right pos- postsurgical psychiatric complications, defned as psychiatric disor- terior temporal region [53]. She found that personality dis- orders were a risk factor associated with this type of complications. In the study carried out en [30] identifed 11 with a psychotic disorder presurgically. The 822 Chapter 64 surgical procedure had no impact on the psychotic disorders post- surgery. In a series of fve patients with a chronic psychotic dis- or obtaining gainful employment. Five out of the six patients achieved a seizure-free out- tations of becoming more independent, not only as it pertains to come and there was relative improvement in the psychotic disor- their ability to drive but in other areas of their life. Tese same authors reported an additional case in some cases seizure freedom can have a negative impact on fam- of a 45-year-old female patient with a 30-year history of epilepsy ily dynamics. In ‘give up’ their role in life of a ‘care taker’ without which they cannot a recently published study, D’Alessio reported on the postsurgical ‘function’. Six patients (43%) did not and invariably are bound to lead to confict when patients try to develop any psychiatric complications, three patients (21%) with become more independent. In fact, divorce is not an uncommon chronic interictal psychosis continued with no exacerbation, three ‘complication’ of successful epilepsy surgery. By the same token, patients (21%) developed acute and transient psychotic symptoms, some patients who for a long period of time became too depend- and two patients (14%) developed de novo depression. All of these case series exemplify that patients with interictal must be part of any presurgical evaluation and all couples and fam- psychosis can successfully complete a presurgical evaluation. Impact of presurgical psychiatric illness on postsurgical seizure outcome It is counterintuitive to associate a presurgical psychiatric history Impact of presurgical psychiatric history with a postsurgical seizure outcome. Likewise, Kanner cortex and the identifcation of patients at risk for postsurgical cog- et al. Unfortunately, this is not always the others by the shorter postsurgical follow-up period, which may ac- case. A review of the literature identifed the following variables as count for the diferences. Tey found included working before surgery, achieving a seizure-free state, that preoperative anxiety disorders and personality disorders were a negative lifetime history of depression and female gender [59]. Of note, there was no diference among centres in which the same Tese data raise the question: Is it possible that a psychiatric his- (30%) or diferent (33%) psychiatrists performed the evaluation. The explanations for this phenomenon remain unknown chiatric aspects of epilepsy are more ‘attuned’ to potential postsur- at this time. Yet, several theories have been postulated by this au- gical psychiatric complications. Tese data also raise the question thor [66,67] but their review is beyond the scope of this chapter. In fact, 35 centres (75%) voiced concerns on the failure to Psychiatric aspects of paediatric epilepsy obtain in-depth psychiatric evaluations. In of pervasive developmental disorder, which was not present post- contrast, only 4 out of the 12 centres (33%) with an epilepsy team surgically in two of 23 patients who were diagnosed with this con- psychiatrist relied on these criteria. Afer all, most neuropsychological eval- the majority of which (73%) consisted of frontal resections [69].

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An understanding of basic physiological principles is essential to competently answer the probing management-style questions anxiety symptoms checklist cymbalta 40 mg buy without prescription. Manoeuvres – Suction anxiety symptoms muscle tension buy cymbalta 40 mg on-line, head-tilt anxiety symptoms only at night order discount cymbalta on line, chin lift, jaw thrust Adjuncts – Oro/naso-pharyngeal airways Definitive – Oro/naso-tracheal intubation, surgical airway (cricothyroidotomy, tracheostomy) What types of tracheostomy do you know of? Elective versus emergency Cuffed versus uncuffed Fenestrated versus unfenestrated Open versus percutaneous Silver metal versus plastic What complications should you be aware of with a tracheostomy? Bleeding – May aspirate Subcutaneous emphysema Local infection Tracheal stenosis Damage to brachiocephalic vein from misplacement with tube change How might you assist ventilation? Respiratory acidosis – Hypoventilation which has both central (depression of the respiratory centres, e. Raised lactic acid (secondary to shock, infection and hypoxia) Raised ketoacids (secondary to diabetes mellitus, alcohol) ‘Fixed’ acids (renal failure) Ingested acids (drugs and toxins) Figure 5. In view of the clinical history and symptoms and signs, bowel ischaemia secondary to a mesenteric embolic event must be excluded. A, B, C Careful assessment for inhalational injury (facial burns, singed hair, cough, hoarseness, stridor, carbonaceous sputum) with a low threshold for intubation Wallace’s rule of nines (head 9%, single arm 9%, anterior trunk 18%, posterior trunk 18%, single leg 18%, genitalia 1%) Partial thickness (red/white, blistering, sensate) versus full thickness (white, leathery, desensate) Early discussion with burns unit to arrange transfer if necessary How would you resuscitate them? In addition to maintenance fluid, replacement crystalloids are given at 4 mL/kg body weight/% burn of total body surface area over 24 hours (Parkland formula). Bacteraemia is the presence of bacteria in the blood as confirmed by microbiological culture. Sepsis is a systemic illness caused by microbial invasion of normally sterile body sites that is associated with one or more clinical signs. Severe sepsis is defined as sepsis associated with organ dysfunction, hypoperfusion abnormality or sepsis-induced hypotension. Multi-organ dysfunction syndrome (or multi-organ failure) is the presence of severe, acquired dysfunction of two or more organ systems in an acutely ill patient such that homeostasis cannot be maintained without intervention. Pre-renal failure Inadequate renal perfusion secondary to volume depletion Where are the commonest surgical fluid losses? Haemorrhage Gastrointestinal Sepsis Third space What is oliguria and how would you manage it? If still not controlled, discuss with pain team or anaesthetist for adjuncts or alternatives. Has an internal safety mechanism to prevent opioid overdose because of the ‘lock out’ time period. If the patient administers too much they fall asleep and stop pressing the button. Arrange appropriate specialist consults early with respect to the areas of concern, specifically asking for approval for surgery. If necessary delay the surgical procedure until it is safe to proceed, unless it is an emergency and the risk is outweighed by the gain. Inform the operating team and bookings office early regarding possible delays to the surgical procedure. Presence of pain – Painless jaundice may suggest malignancy Presence of pale stools and/or dark urine, pruritus – Suggests obstruction of the biliary tree, e. Pre-hepatic causes Haemolysis Gilbert’s syndrome and other congenital enzymatic defects in bilirubin metabolism (e. Crigler–Najjar syndrome) Dyserythropoiesis Hepatocellular causes (cirrhosis) Congenital/genetic – Haemochromatosis, Wilson’s, α1-antitrypsin deficiency Alcohol Drugs and toxins Autoimmune, e. However, in worsening obstructive jaundice, immediate biliary drainage and stenting may be required initially. Altered fluid balance – Hypoalbuminaemia (leading to peripheral oedema and ascites), secondary hyperaldosteronism (leading to sodium retention and hypokalaemia) Acid–base disturbances Coagulopathy Hepatorenal syndrome (leading to renal failure) Altered drug metabolism Metabolic derangements, e. Peripheral – Antecubital, forearm, saphenous veins Peripheral venous cut down – Great saphenous vein Central – Femoral, subclavian, internal jugular veins (Seldinger technique) Shortly after central venous line insertion, the patient becomes hypoxic, tachypnoeic and tachycardic. Insert a large bore cannula into the second intercostal space, mid-clavicular line on the side of the suspected pneumothorax. Direct (pulmonary) Pneumonia Chest trauma Aspiration pneumonitis Near-drowning Inhalational injury Figure 5.

Sigmor, 54 years: Allergic individuals also express it on monocytes, eosinophils, B and T cells, but not mast cells or Langerhans cells, eosinophils, and monocytes. The test was devel- formed studies suggestive of a role for autohemagglutinins oped in the 1940s to demonstrate autoantibodies on the sur- in acquired hemolytic icterus, and Chauffard and Vincent face of red blood cells that failed to cause agglutination of the pointed to the action of hemolysins in the production of cells.

Asaru, 21 years: Saccharated iron oxide is a colloidal iron oxide employed to investigate the phagocytic capacity of mononuclear A neutrophil leukocyte (Figure 2. Treatment: Treatments may include medications for pain, assistive 468 devices to reduce weight on the bone or joint, core decompression, osteotomy, bone graft, arthroplasty (total joint replacement), electrical stimulation, or any combination of therapies to encourage the growth of new bone.

Treslott, 44 years: Egg antigens may induce enteric strongyloides infection to produce this condition. The pain of plantar fasciitis is most severe on taking the first few steps after having not borne weight and is made worse by prolonged standing or walking.

Ronar, 22 years: Applying a small amount of suction through to the inside of the cell and other substance from inside the pipette forms a seal tight enough such that ions can the cell to the outside. If a larger diameter probe is used in fbrous tissue, excessive vibration amplitude the vibrating probe can be pressed into unprotected will be required to get the probe to pass through the skin away from the incision site and will cause a friction tissue.

Jose, 40 years: Secondly, direct vasodilators cause unpleasant side effects such as flushing, headache, and palpitations. Burnet proposed lymphoid cells genetically programmed to synthesize one type of antibody.

Stan, 33 years: It also eluding coronary stents have been used effectively to reduce suppresses delayed type hypersensitivity. This is a good opportunity to provide some statistics to allay the “While thinking about each relative, think about discomfort.

Ugrasal, 32 years: Normally, this first cell should have two working copies of the R B I gene, one from each parent. There is little evidence fewer worms develop higher titers of antilarval antibodies, of cellular immunity and granuloma formation in amebic which increases resistance to larval challenge.

Emet, 38 years: Expression o f the hom eobox gene Pitx2 in neural crest is required for optic stalk and ocular anterior segment develop­ vein occlusion2U Objective signs of an optic neuropathy m ent. Two ‘pedicles’, the gastrosplenic and lienorenal ligaments connect the hilum of the spleen to the greater curvature of the stomach and the anterior surface of the left kidney, respectively.

Corwyn, 30 years: Both enzyme induction and inhibition can occur simul- of ± 10% over a 12-h dosage interval. The two H chains are identical to each other and con- tain about 450 amino acids, which may be either of α, γ, µ, δ and ε chains.

Sanford, 58 years: Treatment: Surgery in infancy or early childhood is required to prevent progressive neurologic deficit. Use the plastic guard on the needle to mark the depth of the needle in this location.

Mojok, 28 years: These fibers are called expansions and are subject to strain; the tendon proper is subject to the development of tendinitis. Alternative monotherapy Individuals should be monitored carefully not only for seizure ac- As summarized in the preface of this book , the vogue for antiepi- tivity, but also for potential comorbidities (particularly psychiatric leptic drug monotherapy dates from the late 1970s and the advan- conditions) and adverse drug efects [5,9].

Frithjof, 26 years: Albinism is described in detail elsewhere in this however, the term “infantile nystagmus” is preferred because textbook. The maviruses or formiviruses that induce persistent infections Coombs’ test is negative, and acetylcholine esterase activity unaccompanied by clinical disease.

Sugut, 56 years: High-frequency oscillations and other electrophysio-logical for identifcation of network-specifc cellular or molecular biomark- biomarkers of epilepsy: underlying mechanisms. Fosphenytoin, a phenytoin prodrug Less than 5% of a phenytoin dose is excreted in urine unmetabo- which is water-soluble and well absorbed afer intramuscular ad- lized.

Torn, 31 years: Management of Childhood Epilepsy Syndromes 179 with a strong genetic loading [11]. One mol Filtration, Bulk Flow and Solvent Drag per liter depresses the freezing point of water by 1.

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